Childhood Cancer Presentation PDF

What is Cancer? Occurs from an alteration in cellular regulation resulting in out of control cell growth Life threatening Comparison Chart 24.1 Childhood vs Adult Cancer Warning signs: fatigue, pallor, frequent or recurrent infection, or easily bruising Infiltration, obstruction, or compres...

What is Cancer? Occurs from an alteration in cellular regulation resulting in out of control cell growth Life threatening Comparison Chart 24.1 Childhood vs Adult Cancer Warning signs: fatigue, pallor, frequent or recurrent infection, or easily bruising Infiltration, obstruction, or compression by a tumor bone or abdominal pain, pain in other body parts, swelling, or unusual discharge. Common Types of Childhood Cancers Blood  Other types Leukemias (ALL (Most common),  Neuroblastoma AML)  Osteosarcoma Hodgkin Disease  Wilms Tumor Non-Hodgkin Lymphoma  Rhabdomyosarcomas (Multiple Sites) Brain  Retinoblastoma Medulloblastoma (Most common) Brainstem glioma Ependymoma Astrocytoma Cardinal Signs & Symptoms of Cancer in Children OVERT SIGNS COVERT SIGNS A mass, swelling Bone or abdominal pain Purpura Pain in other parts of the body Pallor Weight loss Headache Whitish reflex in the eye Vomiting early in the Persistent lymphadenopathy morning Change in balance, gait or Recurrent or persistent fever personality Frequent or severe infection Fatigue, malaise Easy bruising Leukemia Primary disorder of bone marrow (normal elements placed with abnormal/immature WBCs (blasts) Leukemia accounts for about 1/3 of all childhood cancers Classification is based on type of WBC that becomes neoplastic and the immaturity of the neoplastic cell Leukemia may be classified as acute or chronic, lymphocytic or myelogenous Acute lymphocytic/lymphoblastic leukemia – ALL Acute myeloid/myelogenous leukemia - AML Chronic lymphocytic leukemia - CLL Chronic myeloid/myelogenous leukemia – CML Acute - rapidly progressive disease cells w/o normal function Chronic – progress more slowly  cells retain some of their normal function Leukemia COMPLICATIONS OF LEUKEMIA Metastasis - blood, bone, CNS, spleen, liver, or other organs Alterations in growth Late effects – neurocognitive, ocular, cardiovascular, thyroid dysfunction With advances in treatment - most cases of childhood leukemia are curable However, children who experience relapse or present with advanced disease have a poorer prognosis  Acute Lymphoblastic Leukemia Most common form of childhood cancer (85% occur between 2-10 yrs. of age) PATHO: exact cause is unknown More common in white children than other races Genetic factors & Chromosome abnormalities Classified by type of cell involved—T cell, B cell, early may play a role pre-B cell, or pre-B cell. Abnormal lymphoblasts are fragile, immature, Most children achieve initial remission if appropriate and lack infection- fighting capabilities treatment is given These lymphoblasts grow excessively and Cure rate= 70% replace normal cells in the bone marrow Prognosis base on: Bone marrow becomes unstable leading to  WBC count at diagnosis anemia, neutropenia, and thrombocytopenia  Higher the count worse the prognosis  Type of cytogenetic factors As the bone marrow expands to hold excessive  Immunophenotype leukemic cells, joint and bone pain may occur  Age of diagnosis Leukemic cells may invade lymph nodes, liver, or  Extend of extramedullary involvement spleen diffuse lymphadenopathy or Complications: Infection, hemorrhage, poor growth, and hepatosplenomegaly. CNS, Bone, or testicular involvement With CNS spread vomiting, HA, seizures, coma, vision alterations, or cranial nerve palsies Acute Lymphoblastic Leukemia THERAPEUTIC MANAGEMENT Chemotherapy to eradicate the leukemic cells & restore normal bone marrow function CNS prophylaxis is provided at each stage ◦ to prevent spread of leukemia to CNS Length of treatment & choice of medications based on: child’s age, risk category, subtype determined by bone marrow analysis Stages of leukemia treatment ◦ Induction ◦ Consolidation ◦ Maintenance HSCT may be necessary for relapsed or less responsive leukemia  Acute Lymphoblastic Leukemia NURSING ASSESSMENT PHYSICAL EXAMINATION HEALTH HX ◦ inspect for petechiae, purpura, or present illness unusual bruising chief complaint ◦ fever ?, s/s of infection common s/s ◦ auscultate adventitious breath medical HX sounds risk factors ◦ note location & size of lymph nodes immunization HX ◦ palpate enlarged liver, spleen; abd specifically, varicella zoster May lead to disseminated, overwhelming infection pain? Take Note! Changes in behavior or personality, headache, irritability, dizziness, persistent nausea or vomiting, seizures, gait changes, lethargy, or altered level of consciousness may indicate CNS infiltration with leukemic cells. Acute Lymphoblastic Leukemia SIGNS & SYMPTOMS RISK FACTORS Fever – persistent, Nausea or vomiting recurrent unknown Male gender Headache cause Lymphadenopathy Age 2-5 years Anorexia Hepatosplenomegal y Caucasian race Recurrent infection Bone & joint pain Down syndrome, Shwachman Fatigue, weakness, Excessive bruising malaise, or listlessness syndrome, or ataxia- Abnormal WBC counts telangiectasia Pallor Infiltration of spleen, liver, lymph glands X-ray exposure in utero Unusual bleeding or causing enlargement & bruising eventually fibrosis Previous radiation-treated Abdominal pain Sore throat cancer Acute Lymphoblastic Leukemia LAB & DIAGNOSTIC TESTS CBC- low Hgb & Hct, decreased RBCs, decrease platelet count, and elevated, normal or decreased WBC count Peripheral blood smear- blasts present Definitive DX Bone marrow aspiration/biopsy- will show greater than 25% lymphoblasts Used in classifying leukemia helps guide treatment Lumbar puncture- determine if leukemic cells have infiltrated CNS Liver function tests & BUN/Creatinine- determine liver and renal function  If abnormal, may preclude treatment with certain chemo agents Chest radiography- pneumonia or mediastinal mass Acute Lymphoblastic Leukemia NURSING Take Note! MANAGEMENT Managing disease complications Blood products administered to children with ◦ infection, pain, anemia, bleeding, & hyperuricemia any type of leukemia should be ◦ irradiated Managing the adverse effects r/t to treatment ◦ cytomegalovirus (CMV) negative ◦ blood product transfusion for the treatment of severe anemia ◦ leukodepleted or low platelet levels with active bleeding This treatment of blood products before Reducing Pain –pain r/t disease + treatment transfusion will decrease the amount of antibodies in the blood, an important factor ◦ Head, neck, legs, & abdomen- Most common areas in preventing GVHD should HSCT become ◦ Distraction techniques- music, TV, or games necessary at a later date. ◦ Mild analgesics (acetaminophen) – acute episodes of pain ◦ EMLA cream prior to IV, port access, LPs, or bone marrow aspiration ◦ Applying heat or cold ◦ Narcotic analgesics – acute severe pain, palliative chronic pain Acute Myelogenous Leukemia AML – 2nd most common type of Induction phase of AML leukemia in children ◦ requires intense bone marrow suppression Peaks during the adolescent years ◦ prolonged hospitalization ◦ AML is less responsive to treatment than AML affects the myeloid cell ALL progenitors or precursors in the bone marrow, resulting in malignant Toxicity from treatment is more common in (invasive and fast-growing) cells. AML and is likely to be more serious than with ALL. Classification system ◦ empiric broad-spectrum antibiotics and ◦ French–American–British (FAB) prophylactic platelet transfusions may be ◦ eight subtypes - M0 to M7 prescribed. ◦ useful for determining treatment. After remission is achieved, children require The long-term survival rate for intensive chemotherapy to prolong the childhood AML is about 50%. duration of remission. HSCT is often required in children with AML - Complications - treatment resistance, depending on the subtype infection, hemorrhage, & metastasis Acute Myelogenous Leukemia NURSING ASSESSMENT HEALTH HX - s/s, including recurrent infections, fever, or fatigue PHYSICAL EXAMINATION MEDICAL HX - risk factors: ◦ Note skin pallor & salmon-colored or blue-gray ◦ Hispanic race papular lesions ◦ previous chemotherapy ◦ Palpate skin - subcutaneous rubbery nodules ◦ genetic abnormalities ◦ Palpate - lymphadenopathy ◦ Down syndrome ◦ Fanconi anemia ◦ Note headache, visual disturbance, or signs of ↑ ICP ◦ neurofibromatosis type I ◦ Shwachman syndrome ◦ vomiting, indicating CNS involvement ◦ Bloom syndrome ◦ WBCs - extremely elevated - hyperleukocytosis ◦ familial monosomy 7 ◦ Bone marrow aspiration - > 20% blast cells Acute Myelogenous Leukemia NURSING MANAGEMENT AML is similar to that of the child with ALL Take Note! Nursing interventions focus on At the time of diagnosis, some children with managing the adverse effects of AML present with a WBC count above treatment and preventing 100,000 (hyperleukocytosis); this results in venous stasis and backup of blast cells in infection. small vessels, causing hypoxia, hemorrhage, and lung or brain infarction. Hyperleukocytosis is a medical emergency. These children require leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts. Lymphomas Neoplasms of lymphoid tissues – component of immune system - lymph nodes, thymus, spleen 10-15% of childhood cancer Two categories Hodgkin Lymphoma/Hodgkin disease affect lymph nodes located closer to the body’s surface (cervical, axillary, & inguinal areas) Non-Hodgkin Lymphoma – NHL – more than dozen types affect lymph nodes located more deeply inside the body Lymphomas result when a lymphocyte begins to multiply and crowd out health cells Hodgkin Disease Malignant B lymphocytes grow into the lymph tissue- Usually starting in one general area of lymph nodes Cause of Hodgkin disease - being researched - appears to be a link to Epstein–Barr virus infection Reed–Sternberg cells (giant transformed B lymphocytes with one or two nuclei) differentiates Hodgkins disease from other lymphomas. Most common in adolescents and young adults Rare in children younger than 5 y/o More common in boys than girls Hodgkin Disease In addition to the traditional staging - I through IV - depending on the amount of spread also classified as: ◦ A (asymptomatic) ◦ B (presence of symptoms of fever, night sweats, or weight loss of 10% or more) Prognosis depends on the stage of the disease, tumor bulk, and A or B classification ◦ disease classified as A generally carries a better prognosis Overall, children with Hodgkin disease have a 5-10 year survival rate of over 90% Complications of Hodgkin disease include liver failure and secondary cancer such as acute nonlymphocytic leukemia and NHL. Hodgkin Disease THERAPEUTIC MANAGEMENT Chemotherapy w/ combination of Stage I disease – involved-field drugs - the treatment of choice radiation Radiation therapy - may be Stage II or III disease – extended necessary field radiation (involved areas plus adjacent nodes) or TOTAL NODAL IRRADIATION (entire axial lymph HSCT may be an option for those node system) who do not go into remission or who experiences relapse Stage IV disease - chemotherapy Hodgkin Disease NURSING NURSING ASSESSMENT MANAGEMENT focuses on addressing the adverse HEALTH HISTORY – s/s effects of chemotherapy or ◦ Recent weight loss, fever, drenching night sweat, anorexia, malaise, fatigue, or pruritus radiation RISK FACTORS ◦ prior Epstein–Barr virus infection SIGNS & SYMPTOMS ◦ family history of Hodgkin disease Enlarged, rubbery, firm, NONTENDER, movable ◦ genetic immune disorder nodes in cervical & supraclavicular area ◦ HIV infection May notice the “sentinel” node enlargement – left clavicle first in children Evaluate respiratory status- Mediastinal mass complication Other s/s depend on extent and location of involvement Palpate  Mediastinal lymphadenopathy – persistent ◦ Enlarged lymph nodes- may feel rubbery & tend to occur in nonproductive cough clusters  Enlarged retroperitoneal nodes – abdominal pain ◦ Abdomen for hepatomegaly or splenomegaly  Hepatomegaly, splenomegaly  Low-grade or intermittent fever  Anorexia, malaise, fatigue, pruritis, nausea, recent weight loss, drenching night sweats Hodgkin Disease Diagnosis DIAGNOSIS Biopsy CBC – normal or anemia Renal Test LFT Gallium scans, PET, CT Lymphangiogram – determines involvement in all lymph nodes CXR – mediastinal mass Tissue sampling – Reed-Sternberg cells Non-Hodgkin Lymphoma NHL results from mutations in the B and T lymphocytes that lead to uncontrolled growth NHL tends to affect lymph nodes located more deeply within the body. Spreads by the bloodstream, in children is a rapidly proliferating, aggressive malignancy that is very responsive to treatment Prognosis depends on the cell type involved & the extent of the disease at diagnosis 90% of children with localized NHL have disease-free long-term survival Non-Hodgkin Lymphoma THERAPEUTIC MANAGEMENT Remission is induced with chemotherapy and followed with a maintenance phase of chemotherapy lasting about 2 years. Tends to spread easily to the CNS - CNS prophylaxis similar to that used in leukemia is warranted. Autologous bone marrow transplantation may be used in some children. Multi-agent chemo; correct metabolic state Non-Hodgkin Lymphoma NURSING ASSESSMENT SIGNS & SYMPTOMS Abdominal cramping, pain Symptomatic for only a few Anorexia days to a few weeks before Vomiting Weight loss diagnosis b/c disease progresses so quickly Diarrhea, constipation Ascites New onset & location of pain Painless, enlarged lymph nodes Obstruction or lymph node swelling Lymphadenopathy, abdominal mass Risk factors: Take Note! ◦Congenital immune Cough, dyspnea, orthopnea, facial edema, or deficiency venous engorgement may indicate mediastinal disease in the child with NHL. ◦Acquired immune deficiency This is an EMERGENCY requiring rapid treatment. Non-Hodgkin Lymphoma DIAGNOSIS NURSING MANAGEMENT Determine DX Directed toward managing the Lymph node biopsy adverse effects of chemotherapy Bone marrow aspiration Determine extent of metastasis CT CXR Bone marrow results Liver and renal function studies CBC normal unless bone marrow is involved LP Brain Tumors Most common solid tumor of childhood – 2nd most common cancer in children More than half of brain tumors arise from the posterior fossa; the rest are supratentorial Causes=unknown ◦ As the tumor grows exerts pressure on the brain compressing vital structures, blocking CSF fluid flow, or edema= increased ICP Prognosis depends on the location of the tumor and extent of tumor Low grade and those fully resectable= better prognosis vs deeper, more invasive, making them difficult to resect Complications of brain tumors include hydrocephalus, increased intracranial pressure, brain stem herniation, and negative effects of radiation such as neuropsychological, intellectual, and endocrinologic sequelae. Brain Tumors THERAPEUTIC MANAGEMENT Surgery – total removal of tumor w/o Bone marrow transplantation residual neurologic damage Supportive care (for the side Radiation therapy – Reserved for effects of the tumor or children ↑3 y/o treatment) d/t long term cognitive effects Rehabilitation (to regain lost Chemotherapy motor skills and muscle Steroids strength; speech, physical, and occupational therapists may be Antiseizure medications involved in the healthcare team) Ventriculoperitoneal shunt- for Antibiotics hydrocephalus Continuous follow-up care  Brain Tumors NURSING ASSESSMENT HEALTH HX – common s/s PHYSICAL EXAMINATION CONT. N/V, HA, unsteady gait, blurred or double vision, seizures, motor abnormalities/hemiparesis, Note alteration in gag reflex, cranial nerve palsy, weakness, atrophy, swallowing difficulties, lethargy, or irritability behavior/personality changes, irritability, FTT, or developmental delays Note the child’s posture. MEDICAL HISTORY FOR RISK FACTORS: Check pupillary reaction, noting size, equality, ◦ history of neurofibromatosis reaction to light, and accommodation ◦ tuberous sclerosis ◦ prior treatment for CNS leukemia Measure B/P - which may w/ ↑ICP PHYSICAL EXAMINATION In the infant, palpate the anterior fontanel for bulging Observe for strabismus or nystagmus, “sunsetting” eyes, head tilt, alterations in coordination, gait Take Note! Assess deep tendon reflexes - hyperreflexia disturbance, or alterations in sensation A fixed and dilated pupil is a neurosurgical emergency.  Brain Tumors DIAGNOSIS MRI CT – computed tomography PET – positron emission tomography Single photon emission Signs and Symptoms Neurologic tests LP w/ CSF evaluation for AFP or HCG Brain Tumors NURSING MANAGEMENT PREOPERATIVE CARE Monitor for ↑ ICP; avoiding activities that cause transient ↑ ICP Administer dexamethasone - decrease intracranial inflammation Administer stool softener - prevent straining w/ bowel movements Assess pain level, level of consciousness, pupillary responses Educate about possible intubation & ventilation post-op VP shunt placement for hydrocephalus Shave hair Provide emotional support Do not stress that surgery will take away symptoms ◦ headaches and cerebellar symptoms may be aggravated ◦ vision may not be improved Brain Tumors Take Note! Observe preoperatively and postoperatively for signs of BRAIN STEM HERNIATION such as opisthotonos, nuchal rigidity, head tilt, sluggish pupils, increased blood pressure with widening pulse pressure, change in respirations, bradycardia, irregular pulse, and changes in body temperature. Brain Tumors POSTOPERATIVE CARE Regulate fluid administration Environmental stimuli Administer - mannitol or Headache is common hypertonic dextrose -  decrease Assess pain cerebral edema Vital signs, pupillary responses, level Increased intracranial pressure – of consciousness sluggish, vomiting, dilated or unequal  Extreme lethargy may be present for pupils several days post-op Assess dressing site-for CSF or Headache, pain – give analgesics bleeding Hyperthermia Document – head, face, neck ◦ Infection, cerebral edema, or edema disturbance of hypothalamus Administer eye lubricant, cool compresses ◦ Antipyretics, sponge baths –  temp Restraints – may be needed to slowly prevent dislodging of tubes/lines Brain Tumors POSTOPERATIVE CARE Avoid placing child on the operative side Position the child on the UNAFFECTED side Head of the bed flat or at the level prescribed by the neurosurgeon Side positioning is usually preferred Do not elevate foot of bed increase ICP or contribute to bleeding When changing the child’s position, maintain the head in alignment with the remainder of the body Neuroblastoma Tumor arising from embryonic neural crest cells; most common extracranial solid tumor Most frequently occurs in the abdomen (mainly adrenal gland) 2nd most frequently occurring solid tumor in children 90% diagnosed before the age of 5 years; occurring more often in boys than girls Staging at diagnosis determines the course of treatment and prognosis Prognosis depends on the tumor stage, age at diagnosis, location of tumor, and location of metastasis. Metastasis to the bone= worse prognosis vs Metastasis to skin, liver, or bone marrow Those who relapse after initial treatment tend to have a dismal prognosis In addition to metastasis, complications may include nerve compression, resulting in neurologic deficits. Neuroblastoma THERAPEUTIC MANAGEMENT Must be surgically removed Chemo & radiation are given to all except those with Stage I disease that can have the tumor completely resected Neuroblastoma DIAGNOSTIC NURSING ASSESSMENT PROCEDURES HEALTH HX – s/s depend on the location of the CT, MRI primary tumor and extent of metastasis ◦ Parents often first to notice swollen/asymmetric abdomen CXR, bone scans, skeletal survey ◦ Document bowel/bladder function (watery diarrhea), Neurologic symptoms, bone pain, Bone marrow aspiration & biopsy anorexia, vomiting, or weight loss. Biopsy of primary tumor or PHYSICAL EXAMINATION ◦ neck/facial swelling, bruising above the eyes, or metastatic lesions edema around the eyes -metastasis to skull bones Blood tests - CBC; blood chemistry; ◦ pallor or bruising - bone marrow metastasis kidney & liver function tests ◦ cough or difficulty breathing; wheezing ◦ lymphadenopathy - especially cervical 24-hour urine – HVA (homovanillic ◦ firm, nontender abdominal mass acid); & VMA (vanillylmandelic ◦ Hepatomegaly/splenomegaly acid) Neuroblastoma NURSING MANAGEMENT Post-op care depends on the side of tumor removal- often the abdomen Provide routine care for abdominal surgery Nursing care r/t chemo and radiation Provide emotional support Referrals to help children/family copy with potentially poor prognosis Sarcomas Bone and soft tissue tumors in children. Adolescence – most often DX w/ bone tumors ◦ most common bone tumors – Osteosarcoma, Ewing sarcoma Younger children - most often DX w/ soft tissue tumors ◦ most common soft tissue tumor - rhabdomyosarcoma Bone tumors often go undiagnosed, as adolescents frequently seek care for traumatic events and the pain suffered with a bone tumor may initially be attributed to trauma.  Osteosarcoma/Osteogenic Sarcoma THERAPEUTIC Occurring most frequently in MANAGEMENT adolescents, white males Surgery is necessary(biopsy, resections, Arises from the embryonic mesenchymal bone/skin grafts, reconstructions) tissue that forms the bones Most common sites are in the long Chemotherapy- before surgery to bones decrease size; after surgery to ◦ particularly the proximal humerus treat/prevent metastasis ◦ proximal tibia Radiation therapy is NOT helpful ◦ distal femur Radical amputation may be performed, Complications- metastasis (lungs & other bones) & recurrence of disease but often teens undergo limb-sparing within 3 years (primarily affecting the procedures lungs) Rehabilitation, including physical and occupational therapy and psychosocial Osteosarcoma/Osteogenic Sarcoma NURSING ASSESSMENT HEALTH HX -pain, limp or limitation of motion first noticed? Dull pain progresses to limp or gait changes; Inspect limb for erythema/swelling; palpate warmth/tenderness and tissues mass if present LAB AND DIAGNOSTIC TESTS CT scan MRI Bone scan Often detected when a child is brought to a medical facility for an injury and a radiograph indicates suspicious bone lesions Osteosarcoma/Osteogenic Sarcoma NURSING MANAGEMENT Teens are usually anxious about possible amputation or limb salvage procedures Educate at the adolescent’s developmental level and ensure that he or she is included in planning treatment ◦ preoperative teaching ◦ care of the stump, if amputation is necessary ◦ prosthesis ◦ crutch walking Provide routine orthopedic postoperative care Provide emotional support ◦ Time to adjust to significant body image change Peer support groups helpful ◦ Melissa’s Living Legacy Foundation/Helping Teens Live with Cancer & The Wellness Ewing Sarcoma Ewing sarcoma is a highly malignant bone tumor; more rare than osteosarcoma Radiation, chemo, and surgical Most commonly occurring in the excision are used in combination pelvis or femur Treatment varies depending on size Most common sits for metastasis - of primary tumor and metastasis at lungs, bone, & bone marrow diagnosis. The prognosis for Ewing sarcoma depends on the extent of metastasis Myeloablative Chemotherapy- Destroys the marrow- may be used Occurs most frequently in boys for metastatic disease followed by Peak incidence occurs between 10 a stem cell rescue transplant and 20 years of age Ewing Sarcoma NURSING ASSESSMENT NURSING MANAGEMENT HEALTH HX – intermittent pain, Before treatment begins - discourage progressively worsens (see clinical active play or weight bearing on the manifestations); Note fever; Pain affected extremity becomes constant and severe, to avoid pathologic fracture at the tumor sometimes interrupting sleep; site swelling/erythema at tumor site Address the adverse effects of DIAGNOSTIC TEST treatment Give honest and direct answers to ◦ CT scan teens with Ewing sarcoma who ask ◦ MRI questions about their disease ◦ Biopsy- Establish diagnosis These children will undergo intensive ◦ Chest CT, bone scan, & bilateral therapy and spend a great deal of time bone marrow- determine extend of in the hospital mets Depending on the age of the child: fantasy play, art or pet therapy, drama, writing, humor, and/or music may help Rhabdomyosarcoma Soft tissue tumor – originating from Highly malignant undifferentiated embryonic Most common site for metastasis – lung mesenchymal cells that would ordinarily form striated muscle Usually DX by 2-5 y/o ◦ cells in muscles, tendons, bursae, and fascia or in fibrous, connective, 70% of all DX by 10 y/o lymphatic, or vascular tissue Prognosis is based on the stage of the disease DX - favorable for stage I disease Most common locations for tumor Complications of rhabdomyosarcoma: ◦ head and neck – in younger ◦ metastasis to lung, bone, or bone children marrow ◦ trunk & extremities – in older ◦ direct extension into the CNS children; adolescence ◦ brain stem compromise ◦ genitourinary tract ◦ cranial nerve palsy Rhabdomyosarcoma THERAPEUTIC MANAGEMENT NURSING ASSESSMENT HEALTH HX Surgery- to remove primary o recent illness tumor is generally performed o when the mass was discovered o whether it has changed since first ◦ Lesions is biopsied to determine noted stage Chemotherapy/Radiation- RISK FACTORS Depending on site/size of tumor to o parental smoking avoid disablitiy o exposure to environmental chemicals o family history of cancer o Neurofibromatosis  Rhabdomyosarcoma NURSING ASSESSMENT PHYSICAL EXAMINATION Abnormalities found depend on the location of the rhabdomyosarcoma – r/t site of tumor and other organs being compressed Note respiratory effort and cough Palpate for lymphadenopathy Palpate for hepatosplenomegaly Take Note! Primary tumors arising in the neck region may compress the child’s airway. Assess work of breathing and lung sounds. Rhabdomyosarcoma LABS & DIAGNOSTIC TEST NURSING MRI or CT of primary lesion MANAGEMENT Chest for metastasis Provide routine postoperative surgical care Biopsy of primary tumor for definitive diagnosis Bone marrow aspiration, biopsy, Assess adverse effects of high-dose bone scan, and skeletal survey to radiation determine metastasis Administer chemotherapy as ordered Assess for adverse effects of chemo Wilms Tumor (Nephroblastoma) Most common renal tumor; 2nd most Most commonly metastasizes common abdominal solid tumor ◦ Perirenal tissues Most commonly occurs between 2-5yrs old ◦ Liver Usually affects only one kidney; can be ◦ Diaphragm both ◦ Lungs Etiology unknown - some cases occur via ◦ Abdominal muscles genetic inheritance ◦ Lymph nodes Associated anomalies may occur with Wilms tumor Complications (metastasis or complications from radiation therapy) Rapid tumor growth and is usually large at ◦ liver or renal damage time of diagnosis ◦ female sterility Prognosis is based on the stage of the disease at DX & metastasis ◦ bowel obstruction Overall survival rate is about 90% ◦ Pneumonia ◦ scoliosis Wilms Tumor (Nephroblastoma) THERAPEUTIC MANAGEMENT Surgery is often the primary form Radiation or chemotherapy may be of treatment administered either before or after ◦ Nephrectomy - surgical surgery. removal of the tumor and In some cases of Wilms tumor, the affected kidney tumor is either too large or located too ◦ treatment of choice close to important internal body ◦ allows for accurate staging and structures, such as organs and blood assessment of tumor spread vessels. Chemotherapy is often used in In these cases, chemotherapy or conjunction with or after the radiation therapy may be used to primary surgical procedure has shrink the tumor to a size more safely been completed removed by surgery.  Take Note! Avoid palpating the abdomen Wilms Tumor (Nephroblastoma) after the initial assessment preoperatively. NURSING ASSESSMENT Wilms tumor is highly vascular HEALTH HX RISK FACTORS and soft, so ◦ hemihypertrophy of the spine excessive Parents typically initially observe the ◦ Beckwith–Wiedemann syndrome abdominal mass associated with Wilms handling of the tumor and then seek medical attention. ◦ genitourinary anomalies tumor ◦ absence of the iris may result in Abdominal pain – r/t rapid tumor growth ◦ family history of cancer tumor seeding HX OF PHYSICAL EXAMINATION and ◦ When mass was discovered metastasis. Monitor BP- HTN in 25% of cases ◦ constipation ◦ vomiting Inspect abdomen for asymmetry/visible mass ◦ anorexia ◦ weight loss Auscultate lungs for adventitious breath sounds ◦ difficulty breathing Palpate lymphadenopathy  Wilms Tumor (Nephroblastoma) LABS & DIAGNOSTIC DO NOT TEST - renal or abdominal Ultrasound PALPATE THE MRI &CT scan – chest & abdominal ABDOMEN  Determine spread/ distant metastasis CBC NURSING MANAGEMENT Preoperative - post signs on door or near bed “NOT to BUN PALPATE the abdomen” Creatinine Provide routine postoperative abdominal surgical care (NG tube) Urinalysis- Hematuria or leukocytes Assess remaining kidney function – I/O q 4o, daily wt, urine specific gravity, fluid levels, IV, B/P 24-hour urine – HVA, VMA  To distinguish between Asses pain & infection, & adverse effects of chemo or neuroblastoma radiation Wilms does not have elevated levels Teach parents the need to protect the remaining kidney Take Note! To avoid injuring the remaining kidney, children with a single kidney should Retinoblastoma Congenital, highly malignant tumor, Inherited or nonhereditary, may be present at arising embryonic neural retina birth, or arise during first 2 years of life cells Nonhereditary - may be associated with 5% of cases of blindness in advanced paternal age & always presents w/ children unilateral involvement Hereditary - inherited via the autosomal Most children are diagnosed by age dominant mode; unilateral or bilateral 5; 5-year survival rate is 90% Complications: unilateral or bilateral ◦ spread to the brain & the opposite eye Tumor may grow forward into the ◦ metastasis to lymph nodes, bone, bone vitreous cavity of the eye or extend marrow, & liver into the subretinal space, causing retinal detachment Secondary tumors ◦ most often osteogenic sarcomas Tumor - may extend into the ◦ may also occur in children who have been choroid, the sclera, & optic nerve treated for retinoblastoma Retinoblastoma THERAPEUTIC MANAGEMENT Goals of treatment ◦ eradicate the tumor ◦ preserve vision ◦ provide a good cosmetic outcome USE: Enucleation (eye removal) of the affected eye - advanced disease or External beam Radiation in the case of a massive tumor with Chemotherapy retinal detachment Laser surgery Moderate vision may be preserved Cryotherapy for most children without advanced disease Or combination of these treatments Retinoblastoma NURSING ASSESSMENT LABS & DIAGNOSTIC Parents are often the first to notice the TESTS Fundoscopic examination “cat’s eye reflex” or “whitewash glow” to Head & eyes (to visualize the the child’s affected pupil tumor) HEALTH HX – Strabismus, orbital CT inflammation, vomiting, HA; Assess pupils for size and reactivity to light- Note MRI leukocoria; erythema, hyphema Ultrasound Late sign is BLINDNESS Determine presence & extent of RISK FACTORS metastasis ◦ family history of retinoblastoma LP ◦ Family hx other cancer ◦ presence of chromosomal anomalies Bone marrow aspiration  Take Note! Educate parents about protecting vision in the remaining eye: routine eye check-ups, Retinoblastoma protection from accidental injury, use of safety goggles during sports, and prompt treatment of eye infections. NURSING Generally, children with one eye should MANAGEMENT notfor Monitor participate side effects of in contact sports. chemotherapy Prepare parents for child’s post-op appearance Eye exams every 3-6 months until age 6, then annually – Eye patch to check for tumor development Face-edematous or ecchymotic Provide for encouragement and emotional support Teach socket care - clean wound Enucleated eyes=prosthetic eye fitted several weeks after removal Eye pad is changed daily ◦ Teach prosthetic eye care ◦ Does not have to be removed daily Assess for bleeding – observe large pressure dressing on the eye socket over Refer to genetic counseling enucleated eyes ◦ children w/ heritable form of retinoblastoma – at puberty b/c of risk of bilateral disease in their offspring Dressing changes to the socket may include sterile saline rinses and/or Children w/ family HX of retinoblastoma antibiotic ointment application. ◦ need ophthalmologic examination shortly after birth & routinely until age 5-6 years SCREENING FOR REPRODUCTIVE CANCERS IN ADOLESCENTS CERVICAL CANCER RISK FACTORS - young age at first intercourse, infection with a sexually transmitted disease, & a history of multiple sex partners Screening Papanicolaou (Pap) Smear- determines abnormal cervical cells and is key part in screening for cervical cancer Most commonly attributed to human papillomavirus (HPV) ◦ HPV vaccine – Gardasil - recommended to be given as a 3-vaccine series to all girls & boys beginning at age 11-12 y/o Counsel all sexually active adolescents to seek reproductive care and take responsibility for their sexual health High response to therapy with cure rate if treated in early stages SCREENING FOR REPRODUCTIVE CANCERS IN ADOLESCENTS TESTICULAR CANCER Uncommon in teens, most frequently diagnosed cancer in males between 20-34 y/o One of the most curable cancers if diagnosed early Screening for testicular lumps ◦Encourage adolescent boys to begin performing testicular self- examinations monthly Nursing Care in the Child with Cancer Infection Complications may Avoid invasive procedures arise secondary to treatment: Avoid contact with infected fever individuals Regular S/S of infection may not be present bleeding Handwashing Aseptic technique anemia protect from injury Do no allow fresh flowers or adequate rest fruits in child’s room nutrition  Preventing infection Neutropenia Precautions: Place the child in a private room. Perform hand hygiene before and after contact with each child. Monitor vital signs every 4 hours. Assess for signs and symptoms of infection at least every 8 hours. Avoid rectal suppositories, enemas, or examinations; urinary catheterization; and invasive procedures. Restrict visitors with fever, cough, or other signs/symptoms of infection. Do not permit raw fruits or vegetables or fresh flowers or live plants in the room. Place a mask on the child when he or she is being transported outside of the room. Perform dental care with a soft toothbrush if the platelet count is adequate. *Children with neutropenia and fever must be started on intravenous broad-spectrum antibiotics without delay to avoid overwhelming sepsis Nursing Care in the Child with Cancer Preventing Hemorrhage – PREVENTING ANEMIA- Assess: Petechiae, purpura, bruising or Limit blood draws to the minimum bleeding volume required Encourage quiet activities/play to avoid Encourage the child to eat an trauma appropriate diet that includes Avoid rectal temps and exams adequate iron Post sign at HOB Administer EPO injections as ordered Avoid IM injections and lumbar punctures Teach families to give the injections If bone marrow aspiration must be at home if prescribed. performed, apply a pressure dressing to the site Active or uncontrolled bleeding transfuse platelets as ordered  Nursing Care in the Child with Cancer MANAGING NAUSEA, VOMITING, AND ANOREXIA Many chemotherapeutic drugs produce the adverse effect of nausea and vomiting, which often leads to anorexia. Taste alterations are common in children who have received chemotherapy. During or after chemotherapy, children may develop an aversion to a food that was previously their favorite. Provide foods the child desires or asks for in order to increase the likelihood of eating. Prevent nausea by administering antiemetic medications prior to the administration of chemotherapy and on a routine schedule around the clock for the first 1 to 2 days rather than on an as-needed (PRN) basis. Herbal or complementary therapies may provide another option for management of nausea. Bright lights and noise may worsen nausea  dimly lit and calm. Relaxation therapy and guided imagery may also be helpful in preventing or treating nausea and vomiting Nursing Care in the Child with Cancer Mucosal Ulceration/Mucositis/Stomatitis Gastrointestinal mucosal cell damage resulting in ulcers Oral ulcers – stomatitis – red, eroded, painful areas in mouth and/or pharynx, may also extend along esophagus and in rectal area Interventions for oral ulcers: Bland, moist soft diet Soft sponge toothbrush or cotton tipped applicator Frequent normal saline mouth rinses Local anesthetics Infant mouth care Perform mouth care before and after a feeding and as often as every 2-4 hours Nursing Care in the Child with Cancer Health Promotion Assess how the normal health care needs of the child are taken care of Dental care Irradiation can cause caries, periodontal disease Encouraged daily tooth brushing and flossing for children with platelet counts above 40,000 and granulocyte counts >500/mm3 Encourage play appropriate for age Encourage seeing peers Nursing Care in the Child with Cancer Long term effects Continue F/U The treatment may produce complications that aren’t apparent until child grows and matures: Psychosocial and physical problems Growth retardation and cognitive impairment Musculoskeletal defects Radiation to head may cause hypothyroidism Abnormalities in tooth formation May also be damage to the heart Secondary cancers Altered function of specific organ systems Remember, death is viewed differently at different stages of development Nursing Interventions for the Terminal Child and Family Express genuine concern Be available Say you are sorry for what is happening Include siblings when possible Encourage them to focus on all senses Gently teach parents what to expect in to comfort the child: caressing, music, sibling’s behaviors (based on age, subtle lighting, movies maturity, inclusion in death process) Keep family informed regarding what is Be aware of “words”—avoid “your happening sister/brother went to sleep” Tell them they are doing a wonderful Refer to support groups and grief job counseling Resources National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch http://pediatrics.cancer.gov/ National Cancer Institute, Fact Sheet http://www.cancer.gov/cancertopics/factsheet/Sites-Types/childhood St. Jude Children’s Research Hospital http://www.stjude.org/stjude/v/index.jsp?vgnextoid=f87d4c2a71fca210V gnVCM1000001e0215acRCRD